Teens at Risk
A Christ-centered Approach to Assessment and Treatment
After youth service a teen girl comes to you and says she believes her friend, who is also in your youth group, has been making herself throw up. Another teen confides he no longer wants to live. A parent comes to you after Sunday service and explains that her teen daughter has been cutting her arms with a razor several times a week.
These situations are becoming more common in today’s churches. It is critical to understand and recognize these complex mental health issues due to their prevalence in youth ministry. It is also essential that youth leaders equip themselves with adequate tools and resources so they can better assist families with teens in managing these situations.
This article provides clinical understanding of three serious mental health issues (self-injury, eating disordered behaviors, and suicide), then integrates clinical theory with a Christ-centered approach.
Self-injury or mutilation is the act of deliberately destroying body tissue as a means of managing or coping with intense feelings. Over the last decade mental health professionals have seen a drastic increase in the amount of self-injurious behaviors. If professionals can recognize and treat this behavior in adolescents, the adolescent has a greater chance of overcoming this form of self-soothing and replacing it with healthy and socially acceptable choices.
Forms of self-injury may include:
- picking and pulling skin and hair
- head banging
- excessive body piercing/tattooing
The causes and severity of self-injury vary. Some adolescents may self-mutilate to take risks, rebel, reject their parents’ values, state their individuality, or to be accepted. Others may injure themselves out of desperation or anger, to seek attention, to show their hopelessness and worthlessness, or because they have suicidal thoughts. These children may suffer from serious psychiatric problems such as depression, psychosis, Posttraumatic Stress Disorder (PTSD), and Bipolar Disorder. Some young children may resort to self-injurious acts from time to time but often grow out of it.
Children with mental retardation and/or autism, as well as children who have been abused or abandoned, may also show these behaviors. Research has shown that, when a person harms himself, this rapidly reduces physiological and psychological tension, returning the person to his baseline (normal) state of emotional well-being. Thus, when someone or something triggers an intense, uncomfortable emotion in him (often the person experiencing this emotion does not have a name for it), he lacks adequate coping skills and the ability to tolerate the distress that this feeling is creating in his mind and body. His brain resorts to surviving and will at all cost shut down the emotional state that is overwhelming his system. He may not know how to handle the emotion, but he does know that hurting himself will reduce the emotional discomfort quickly and help him survive.
Habitual invalidation of feelings by parents, primary caregivers, or relationships of importance is a common factor experienced by most individuals who self-injure. Parents or others around them have taught them at an early age that their interpretations of and feelings about the things around them are bad and wrong. In abusive homes parents may have severely punished them for expressing certain thoughts and feelings. This fosters poor modeling for coping effectively with distress and various life circumstances. It is difficult for teens to learn to cope effectively with distress when those around them are not managing their own emotional reactivity.
Although a history of abuse (emotional, physical, and sexual) is common among self-injurers, not everyone who has been abused self-injures. Sometimes invalidation and lack of role models for coping are enough to cause a person to self-injure, especially if his brain chemistry has already primed him for obsessive-compulsive or addictive patterns of response.
The latest research is helping us understand the role that serotonin plays in depression, anxiety, addiction, and self-injurious behaviors. A family mental health history of addiction biochemically predisposes some people to self-injury. This tendency toward impulsivity and aggression, combined with a belief that one’s feelings are bad or wrong, can lead to turning the aggression on self. Of course, once this happens, the person harming himself learns that self-injury reduces his level of distress, and the cycle begins. Some researchers theorize that a desire to release endorphins, the body’s natural painkillers, is equally as reinforcing as the role that serotonin plays.
Eating Disordered Behaviors
Eating disordered behaviors affect a person’s entire life, health, family, and often school or work. Once a young girl starts with the behavior, often there is no end in sight. Staying thin and focusing on how she looks become her main obsession. A day does not go by without thoughts focused on counting calories, weight, and comparing her body image to others. A girl with anorexia starves herself to dangerously thin levels, at least 15 percent below her appropriate weight. Recent research shows there is an increase in the amount of males developing eating disordered behaviors as well.
Symptoms of anorexia
- Low weight
- Weight phobia: Intense fear of gaining weight or becoming fat, even though underweight
- Body image issues: Believing one is fat when she is not, making weight the only thing to judge herself on, denying the medical seriousness of low weight
- Loss of menstrual period: For women who have reached puberty, missing at least three menstrual cycles in a row
Warning signs for adolescents and adults
- Loss of menstrual period
- Dieting obsessively when not overweight
- Claiming to feel fat when overweight is not a reality
- Preoccupation with food, calories, nutrition, and/or cooking
- Denial of hunger
- Excessive exercising, being overly active
- Frequent weighing
- Strange food-related behaviors
- Episodes of binge eating
- 15 percent or more below normal body weight/rapid weight loss
- Slowness of thought/memory difficulties
- Hair loss
Eating disorders are related to self-injurious behaviors in that a person turns her intense emotions inward and copes by controlling food. As with most dysfunctional coping skills, she is trying to meet a healthy need (love, security, acceptance, attention, consistency, etc.) in an unhealthy manner. But whereas a person with anorexia starves herself to dangerously thin levels, those with bulimia eat large amounts of food — sometimes thousands of calories at a time — and then purge the calories out of her body through vomiting, excessive exercise, fasting, laxatives, and other methods.
Unlike anorexia, it is not immediately obvious when persons are struggling with bulimia. Their weight is not low and they often seem healthy. Usually, the only overt physical signs are swollen cheeks or scrapes on their fingers, the result of induced vomiting. Dentists are often the ones to recognize the problem because of damage to teeth from repeated exposure to stomach acid.
If bulimia is severe and prolonged, the medical consequences are extremely serious, especially if the person abuses laxatives. These include injury to the stomach, intestines, esophagus, and damage to the heart and kidneys. Fortunately, many of these medical complications can improve once a person recovers from this disorder.
Symptoms of bulimia
- Binge eating regularly.
- Purging: regular efforts to avoid weight gain, including self-induced vomiting, laxative abuse, diuretics, enemas, other medications, fasting, or excessive exercise.
- Frequency: episodes of binge eating and purging occur, on average, at least twice a week for 3 months.
- Body image issues: making weight the only thing on which one judges herself.
- Excessive thoughts about weight
- Strict dieting followed by eating, bingeing, and eating
- Frequent overeating, especially when distressed
- Bingeing on high-calorie, sweet foods
- Use of laxatives, diuretics, strict dieting, vigorous exercise, and/or vomiting to control weight
- Leaving for the bathroom after meals
- Being secretive about binges or vomiting
- Planning binges or opportunities to binge
- Feeling out of control
- Depressive moods
Suicidal Ideation, Tendencies, and Behaviors
Suicidal ideation is marked by intrusive and repetitive thoughts that the person would be better off if he were no longer living. Thinking about suicide is not the same as planning for suicide with the intent and means to follow through. This is a major distinction in the mental health field, and it is important to understand this when working with teens that display these types of thought patterns. There can also be high-risk behaviors in which a person places himself in harm’s way as a passive-aggressive form of suicidal intent and means. A mental health professional is trained to discern the difference and create a treatment plan that will provide safety from self and others as needed.
Teen suicide warning signs
- Disinterest in favorite extracurricular activities
- Problems at work/school and losing interest in a job/school
- Substance abuse, including alcohol and drug use (illegal and legal drugs)
- Behavioral problems
- Withdrawing from family and friends
- Sleep changes
- Changes in eating habits
- Begins to neglect hygiene and other matters of personal appearance
- Emotional distress brings on physical complaints (aches, fatigues, migraines)
- Hard time concentrating and paying attention
- Declining grades in school
- Loss of interest in schoolwork
- Risk-taking behaviors
- Complains more frequently of boredom
- Does not respond as before to praise
Not all of these suicide-warning signs will be present in cases of possible teen suicide. It is important to watch for two or three signs as indications of depression, or even teen suicidal thoughts.
Indications of a suicide plan
Teens might do some things that could indicate they are contemplating or even planning suicide. Become aware of these actions and use them as starting points to draw teens out and perhaps express what is bothering them. Here are some indications of a suicide plan:
- Actually says, “I’m thinking of committing suicide,” or “I want to kill myself,” or “I wish I could die.”
- There are also verbal hints that could indicate suicidal thoughts or plans. These include such phrases as: “I want you to know something, in case something happens to me,” or “I won’t trouble you anymore.”
- Teen begins giving away favorite belongings or promising them to friends and family members.
- Throws away important possessions.
- Shows signs of extreme cheerfulness following periods of depression.
- Creates suicide notes.
- Expresses bizarre or unsettling thoughts on occasion.
Integration of Knowledge With Practical Application in Youth Ministry
When a teen reports self-injury, anorexia, bulimia, or suicidal thoughts, he is placing a great deal of trust in you. God has provided you with the opportunity to be His hands and feet. Meeting that teen at his place of need will include active listening skills and validating his thoughts and feelings. A teen is facing situations that are causing him to feel alone and or abandoned. Christ asks us to join the teen at this critical stage of life and walk beside him modeling healthy boundaries, managing emotions, and decision making under difficult circumstances. Being present with him in his pain and not over-reacting to the circumstances is an important part of modeling healthy responses.
Throughout the Gospels, Christ models these skill sets for us. One example is when Christ was with the woman at the well. He did not get on the emotional ride with her when she questioned His authority, “Are you greater then our Father Jacob?” (John 4:12). Instead Christ sat with her as she slowly opened up her story. It was then that He reflected back the truth of what she had become (validating her feelings) and then shared with her the truth of who He is. Understand the significance of the divine appointment God has given you with the hurting teen while you recognize the steps of supporting him.
Become comfortable with listening to a teen without attempting to solve his problems too quickly (over-spiritualizing or getting on the emotional ride with him) through active listening and validation skills. A practical tip is to say nothing for the first 5-10 minutes. As the teen shares his thoughts, use nonverbal communication like nodding, eye contact, and “Oh” and “Mm” responses. As you are taking in what he is saying, you have opportunity to process your own thoughts and discern and pray about how to best respond. Meeting the teen at his place of need will not translate into becoming as upset as he is. However, it does mean remaining calm and rational as you begin to formulate an appropriate response.
When we are too quick to respond, over-spiritualize a problem, or get on the emotional ride with him, the teen becomes defensive or will shut down. Actively listen to him by paraphrasing and validating his feelings: “I can see why you are feeling overwhelmed. Anyone in your shoes would feel this way.” Avoid the “yes, but” or “I remember when I …” responses which will reverse the flow of dialog and make it about you and not him.
Many times I tell teens I can understand why they feel that way or acknowledge that the situations they are facing are difficult. I might see they are missing something, but it would not be helpful to point this out nor is it validating their perspective. Teens need to learn how to think through situations and find solutions. Listening will build trust in the relationship and open the door for teens to be receptive to what you have to say. At this stage of development, teens do not have the ability to think with functioning skills like adults; in fact, they will not have the full use of these skills until their early twenties. Therefore, advanced problem-solving skills in emotionally difficult circumstances are challenging for teens.
When dealing with high-risk circumstances like suicide, self-injury, and eating disordered behaviors, you are ethically and morally obligated to involve the teen’s parents. A practical way you can do this, without damaging the trust between you and the teen, might look like this: After listening and validating the teen, it is appropriate to share your concern about his well-being. Then you can state that this is something his parents need to be aware of because it is important to protect him and help him receive professional care. Provide the teen with options as to how he would like his parents to hear about what is going on. You might say, “I know this is a tough decision, so I am going to allow you to decide how your parents should be told. I can call them right now while you are in my office, or we can invite your mom to join us when she picks you up, and we can tell her together. Which do you prefer?” This will empower the teen to begin making decisions during emotional times. If he is too emotionally shut down or reactive, ask him for permission to make the decision.
If a teen is reporting suicidal thoughts or plans, do not let him leave or be alone before telling a parent about this. No matter how angry a teen becomes, remember he told you this because he wanted help and trusted you to make a wise decision. If a teen reports that someone is sexually or physically abusing him, you need to contact child services. If this person, who is abusing this teen, is outside the family, inform parents first. If the abuse involves a family member and she is at risk, then inform child services first. They will assist you in finding a safe place for the teen during the investigation. Keep your local abuse hotline, which is available 24-7, easily accessible.
Not all teens will be willing to approach you if there is a high-risk situation in their life. If you suspect that a teen is struggling with an eating disorder, having suicidal thoughts or cutting, you need to approach her. Sit down with a teen in a nonthreatening way and ask how she is doing. After she is done speaking, gently express your concern. Stay focused on the facts.
If she is resistant, and you suspect the concern is valid, you will need to ethically protect that teen, while working on building trust. Share your concern with her parents within a legally acceptable time period. Not taking this into consideration creates liability issues for you and your church, if the teen should harm herself after you have knowledge of this. After you have taken this step, work on building a relationship with her and look for opportunities to explore the issue further with appropriate boundaries. Most important, pray for the teen and ask God to reach out to her because He knows what she is facing.
An important part of working with youth at risk is consulting with other professionals. There is wisdom in counsel. If you are faced with one of these high-risk situations, discuss it with your senior pastor, coworker, or youth pastor.
Referring to a Mental Health Professional
Eating disorders, self-injury, and suicidal thoughts are all high-risk situations. When faced with these issues, a teen needs to see a mental health professional for a full assessment of the degree of risk and for treatment. Develop referral sources. Be intentional about finding Christian mental health professionals in your area that specialize in working with teens. Many of these professionals are willing to meet with you so you will be comfortable referring teens and families to them. Knowing the professionals you are referring to can help you be more confident when talking about them with teens and parents. While a teen is in therapy, you can continue working with him on spiritual issues. If the parents sign a release of information, you will be able to collaborate with the therapist on the care of the teen.
The situations referred to in this article are from moderate to high-risk situations, suicide being on the high end of the spectrum. If you receive a call about a teen being suicidal or if a teen shares with you his suicidal thoughts, take this situation seriously. Whether the teen is with you or with someone else, he needs to be within line of sight until a mental health professional can assess him. This can be done in a counseling agency, hospital emergency room, or community counseling center.
Pray with the family or teen and explain the importance of his safety. This provides the suicidal teen with the basic needs of safety, security, support, and accountability. If parents do not take the teen for assessment by a mental health professional until morning, advise the parents that it is important to have a plan that will include the buddy system when it is time to sleep. A parent is the best person for this; it is too much responsibility to place on a sibling.
Most teens experiencing suicidal thinking patterns will find it difficult to communicate their thoughts or feelings during a time of crisis. It is important that those involved come across as supportive and safe rather then punishing or angry. Having Scriptures available for such a time can help families in this situation that are looking to you for spiritual guidance.
Although suicide, self-injury, and eating disorders are high-risk situations, they are not beyond the grace and power of our Lord. God is able to heal teens’ lives so these stressors will eventually become part of their testimony and evidence of His power. Rejoice that God is allowing you to be part of this story.